Thank you for agreeing to pay your bill using Automatic Payment. Electronic payment is a time saver for us and we trust you
will find the convenience equally as satisfying.

Banking rules require that you give your approval to pay your bill in this way. The approval is active until you notify us
that you want to stop using Automatic Payment.

Automatic Payment is safe, efficient, and consumer friendly. Banking law protects consumers from ever having to worry about
someone taking money from their account using Automatic Payment in an unauthorized manner.

PREFER TO FILL THIS AUTOMATIC BANK DEDUCTION AUTHORIZATION OUT BY HAND?
CLICK
HERE
FOR A PDF TO PRINT/SEND VIA FAX OR MAIL

1. Please fill out this automatic bank deduction authorization in full. NOTE: *Required Field.
2. Read the Authorize Transactions & Conditions then click the agree check box.
This will then turn on the SUBMIT button.
3. Click the SUBMIT button on the bottom to submit the final form.
NOTE: You will be sent to a Thank You page when your application is successfully submitted.

ResidentialCommercial

Customer Applicant

*Company Name:

*first name:

*last name:

*email:

Mailing Address

*address 1:

address 2:

*city :

*state:

*zip:

country:

acct holder name & address same as
applicant?:

Bank Account Holder Name & Address

*First Name:

*Last Name:

*Addr1:

Addr2:

*City:

*State:

*Zip:

Country:

*phone:

Bank Name & Address

*Bank Name:

*Bank Addr1:

Bank Addr2:

*Bank City:

*Bank State:

*Bank Zip:

Country:

*Account Type:

*Transit/ABA Number:

*Account Number:

*Authorized Charges:

Full PaymentPartial Payment

*Partial Payment Amount: $

Partial Payment Note:

AUTHORIZE TRANSACTIONS & CONDITIONS: I/we hereby authorize George Propane, Inc. to initiate
entries to my checking or savings account at the financial institution listed above. In the event a transaction is returned unpaid
for any reason, I/we also authorize the company to initiate a $35.00 returned item fee. George Propane, Inc. is not responsible
for overdrawn account balances or overdraft fees charged by your financial institution. This authority will remain in effect until
five (5) days after I/we provide written notice to cancel it.

I Agree with the above terms:

Before submitting please make sure of the following

All necessary information has been filled out.

All information is error-free

All information is correct and fraud-free.

For Fraud Prevention purposes, we have recorded your IP Address & the time of your submission.